Tags

Contents

ACLS in OHCA

Background

Sudden cardiac arrest is common and, obviously, very bad. In the US, there are about 500,000 cardiac arrests each year. About half of these cardiac arrests are out of hospital cardiac arrest (OHCA) and the survival rate is pretty poor. The most recent survival estimates put it at 7 – 9.5% in most communities. About 10-12 years ago, the American Heart Association built the 4-step “chain-of-survival.”

Step One – Early access to emergency care
Step Two – Early CPR
Step Three – Early defibrillation

There is little debate about these three steps as the sum of the data supports that they lead to better outcomes.

The 4th step in the chain, however is slightly more controversial; early advanced care. This basically means rapid access to ACLS type resuscitation skills (intubation and intravenous drug therapy). Despite it being the 4th step, ACLS has little evidence to defend it.

Clinical Question

What was the effect on survival in OHCA of adding ACLS to BLS?

Population

All persons > 16 yo who had an OHCA and for whom resuscitation was attempted.

Intervention

Advanced-life-support program whereby paramedics were trained in inutbation, IV line placement and IV medication administration.

Limitations

Author's Conclusions

The results of the OPALS study did not show any incremental benefit of introducing a full advanced-life-support program to an emergency-medical services system of optimized rapid defibrillation.

Our Conclusions

The institution of ACLS into OHCA care improved the rate of ROSC without improving the return of neurologic function (RONF). Increasing ROSC without improving RONF means that there are more patients “alive” without good neurologic outcomes. This is not the goal of OHCA management. Epinephrine, the cornerstone drug in ACLS, in its current recommended regimen may be a major culprit in getting back the heart but not the brain.

Bottom Line

Addition of an advanced life support algorithm to BLS management did not increase the survival to hospital discharge for patients with OHCA.

Read More

by Anand Swaminathan, MD, MPH

Anand "Swami" Swaminathan is an assistant professor of Emergency Medicine in the Ronald O. Perelman Emergency Department and assistant residency director of the NYU/Bellevue Emergency Medicine residency program. His interests are in resuscitation medicine, resident education and cutting the knowledge translation window. Swami is an active contributor and supporter of innovations in medicine, particularly Free Open Access Medical Education (FOAM). He is a contributor to a number of sites including ALiEM, LITFL, ERCast, and The SGEM. Swami is an associate editor for REBEL EM and REBEL Cast. He is also faculty for the Essentials of Emergency Medicine and Deputy Editor of EM: RAP.